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�. APPLICATION FOR PERS!I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the Work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address W, Vi..0 City / eb-vi Lot Size/Acreage Owner's Name �'� L t Address ��✓ `t'"V►-`' [-f �d i� I4'S Phone Contractor f2 ! &C114m, Z"t r Address Zzz 4/,WS EYP License TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION ❑, SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. '" PROP. LINE FOUNDATION S/ AGRICULTURE WELL,_ OTHER WELL: =PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ~ �omsstic/Private t.? ravei Pack ❑ Tracy Type of Casing_. I Specifications /� I'] Public f-1 Other Cl Delta Depth of Grout Sea! �� Ty r ope of Grout!'_-6i l- �l I I irrigation Approx. Depth I ! Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitled if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. CoP* PKG. TREATMENT PLT. 0 Met ho4qSS 1�� Distance to nearest: Well Foundation Property Line 11 OF C___1 01992 LEACHING LINE ❑ No. b Length of lines Total length/siz FILTER SED C) Distance to nearest: Wall Foundation ProperpLAMP I-IFAI 1H SERVICES HEALTHENVIRONMENTAL DIVISION SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county Ordinances, stats laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the parformanco of the work foe which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required ins ctions. Complete drawing on reverse side. r , / Signed X Title: __b r c " Date: FOR DEPARTMENT USE ONLY Application Accepted by i Dale I / Area u Pit or rest Inspection by Date Y /S Final Inspection by G Date /s Additions Comments: 1 !RR lr' �' r<r1�l�at �h--� ` -I Applicant - Return all copies to: San Joaquin County Publi Health Services 4A; Environmental Health mit/Services 445 N San Joaqui O 8 2009, t3tkn, CIA 95201 FEG INF AMOUNT UE AMOUNT REMITTED CK ECEIVED BY 0 TE PERMIT'NO. EM!3 24 tlIEV.f N t D Eft 11.2E